Ruminations by a non-academic general surgeon from the heart of the rust belt.

Thursday, October 15, 2009

Front row seats

This survey paper from Archives of Surgery in August addresses public/health professional viewpoints on end of life interventions, specifically in situations of severe traumatic injuries ultimately resulting in death. It isn't much of a paper. Surveys are bogus. I think there was only a 50% response rate. But whatever. Here's what I want to highlight:

Most of the public (51.9%) and the professionals (62.7%) would prefer to be present in the treatment room as opposed to the waiting room in the ED during resuscitation of a loved one (Table 2). This preference endured even when respondents may witness disturbing sights. If the victim were a child, the preference for being in the treatment room increased to 79.0% of the public and 78.7% of the professionals.

General impressions can be gleaned, which are often just as useful as meticulously parameterized data. And the general impression of this paper---that both the lay public and health care professionals would prefer to be in a trauma bay during the resuscitation of an traumatically injured child---- is just outlandish to me.

On trauma call one day as a 4th year resident, they rolled in a four year old kid from Chicago's south side who had run out into the street and got drilled by a speeding car (hit and run). He lost his vitals the minute he arrived. He was blond and blue eyed and there was dirt under his fingernails and we were pumping his pale, frail chest and finally the Trauma attending performed an ED thoracotomy. His tiny little pink lung erupted through the wound and his heart fluttered uselessly in its pristine diaphanous sac. There was no blood in the chest. He clamped the aorta and massaged the heart directly. Still no vitals. The next maneuver was a debatable one, in retrospect, but it was almost as if he, all of us in the room collectively, felt the need to do something else, to keep working, anything to avoid stopping, admitting futility. The child's belly had seemed to distend during the resuscitation. So the attending opened up his virgin abdomen, hoping to encounter hemoperitoneum, possibly to clamp the supraceliac aorta, possibly to find a specific injury to repair or at least temporize. There was nothing. The translucent, parchment-thin bowels bulged through the incision. There was no blood. His little liver was beautiful, I remember thinking. Nothing to fix. The vitals never came back and the kid died right there in front of us all with lung and loops of intestines spilled out everywhere. The attending closed the wounds himself, alone, the curtain pulled shut...

I think I put three holes in the call room wall right afterwards. How can something like that happen? For what reason? I still carry the kid's newspaper obituary in my wallet, yellowed and deeply creased after all these years. I take it out every so often. It still pisses me off to this day. I don't want to ever see something like that again...

14 comments:

Anonymous
said...

Don't believe the stats either, especially the professional stats. Sure there is an overwhelming need to know that the best were providing the best care. But there would also be the knowledge that you are not running the team - you will not run the team. That your presence would be an interference, a distraction at minimum to the team during critical interventions, IMHO.

I do understand why public family wants to be there. They don't want to leave the injured to "go it alone" or "to die alone". Not to say the professional doesn't share these reasons. This reaction is easier to understand, and actually a true indicator of love. However, the distraction to the staff, and inevitable PTS to the family makes this something I am against in situations such as you have described. Are there any who actually would encourage it?

Family in the trauma room is just asking for lawsuits following a very emotional time. When chest compressions start cracking ribs, I can't imagine wanting to be in the room if it was my family member. It was bad enough doing the chest compressions.

Not disagreeing with you at all, I just have spoken with a few pediatric trauma guys whose default is to allow parents in the room (are there exceptions for extreme cases like you talked about?, I don't know), and they advocate the practice, so I think its pretty common.

In the US, the fire dept usually responds with an amulance crew so you get 2 medics and 3 EMTs on most medicals. The fire captain has the clipboard and records all pt information, so he usually takes the family into another room to gather demograhic info and medical history while we get to work. We start CPR, intubate, and gain IV access during this time. We then usually allow the family to come back in the room in watch of they want, by this time the initial chaos has died down. My experience though is that there is usually no room for family plus EMS personnel, plus equipment, given that they always seem to collapse in a small bathroom down a long hallway up a spiral staircase.

On a side note, I can't believe you have to transport codes by yourself. I always take 2 extra riders on all codes, one for compressions, one on airway, and myself on monitor/drugs. I believe we call that "being in the $#it".

I can't imagine either being present with my loved one or being absent while they underwent resusitation...what if? What if they awoke for just a minute and I wasn't there? And, how would I carry images like those you describe for the rest of my life? It's unimaginable.

There is no reason or purpose for why small children in this life must suffer and die. We live in a broken world.

Performed a lot of CPR's. I generally don't like having the family in the room initially - particularly if a procedure needs to be done. But once the tubes and lines are in I am certainly OK calling in the family to witness what almost always amounts to the end of the CPR(as they do whether or not the family is present). Usually I bring them in towards the end so they can take it all in and say goodbye while they are technically "alive"(only because I haven't called the code yet. No idea if it helps them, but they seem to like the opportunity.

Certainly won't be having the family in the room to watch me do a thoracotomy though. Hell I'm nervous enough in that situation plus if its sucessfull that usually means a bloody mess from an evacuated hemothorax or hemopericardium.

Completely agree with you that the trauma resuscitation/coding a patient is no place for a loved one. I think that when people see this stuff on "ER" or "Grey's Anatomy" without the blood & guts everywhere, it seems rather benign. The reality is far different.

The indifference of the code teams still upsets me. Not necessarily unkind remarks about the patient, but conversation about other subjects and jokes as if he isn't there, as if this event is not about him. Or very clinical, cynical, detached comments about his chances or future if he does survive. Maybe he is still there. Maybe hearing lasts longer than we think.

At least if the family were there that kind of conversation would be curbed.

I believe it should be the right of a family member to be with their loved one. It's about the patient, and their family. It isn't about how comfortable the medical personnel are. It may be the last time the family sees their family member.

Now, if you're screaming and grabbing the doctors and hindering the team's efforts, then that is a different story. I'm talking about someone who can cope.

I was in this situation. I was present for a long rapid response team effort - when the person was conscious, I was at the bedside holding her hand. She did respond to my commands, when she wouldn't to the nurses. When she was not conscious, I stepped back.

I told them I wanted to be there, no matter what. They respected this. I was there for the full code in the ICU, CPR etc. No, it pretty, and it isn't like on TV.

I stood 10 feet away, I didn't need to watch up close, I didn't get in the way. I am so grateful that I was there. In the end, I was the one who told them they could stop (I'm sure they would have soon anyway). But, it was the last gift I could give her.

I wanted to be there, so I could know, 100%, that as best as I could tell, everything went the way it should have. And, I wasn't forced to abandon her at the end. I've seen good, medium, and bad medical care. I wanted to watch, and be sure as best I could.

I got to hold her hand in her last conscious moments. I can't imagine how distraught I would have been, to have been excluded. For me, seeing what's happeneing, even if terrible, is better than sitting in a room wondering. I doubt I am alone.

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